Joey Wahler (Host): They can adversely affect our lungs and breathing. So, we're discussing respiratory illnesses. Our guest, Dr. Rajendra Rampersaud, who's triple board-certified in Critical Care Medicine, Pulmonary Disease, and Sleep Medicine, as well as Chief of Medicine and Intensive Care and leader of the Sleep Center at St. John's Riverside Hospital.

This is the Riverside Radio HealthCast from St. John's Riverside Hospital. Thanks for listening. I'm Joey Wahler. Hi there, Dr. Rampersaud. Thanks for joining us.

Dr Rajendra Rampersaud: Good afternoon, Joey.

Host: So first, what respiratory and pulmonary services does St. John's Riverside Hospital provide?

Dr Rajendra Rampersaud: So, a very good service for the community. Our lab here provides a full width of services. So, for example, we do something called pulmonary function testing. It's a very simple test. It's not very difficult. The patients would basically sit in a chair and breathe in and out of a computerized machine. And this would actually allow us to determine many, many different types of lung disorders. So for example, if the patient was worried they had asthma, if they were told they had COPD, if they had some type of respiratory illness that wanted to be evaluated.

We do sleep testing. The sleep testing that we do, we're an accredited sleep center by the American Academy of Sleep. And there's two main types of testing that we do. So, one is an in-lab test where the patients would actually sleep overnight. Each patient has their own room. We do children all the way up to age 100 if they wanted to have a test. We also do home testing. So for the patients who are concerned about spending a night over in the hospital, they can actually get a small device that would allow us to analyze just sleep apnea.

So, the amazing thing with sleep is there's about 90 different sleep disorders. So, a test in the lab will pick up some more of them. A home test, purely just sleep apnea. We do something called a six-minute walk test. So for example, just say the patient's symptoms are mostly when they're up and about and they wanted to see if their oxygen numbers are dropping. We can assess that very easily. We do pulmonary rehabilitation. This is actually a very, very important thing, given all of the viral infections, all of the respiratory infections that have been happening. So basically, a team of very nice and well-trained respiratory therapists will sort of help you learn exercises and different things. And it sounds weird, but they'll actually teach the patient how to breathe better. We also assess if the patient needs home oxygen. So, say that somebody was told that maybe they may need this at home, we can assess that. And we actually also do CO laser therapy for those patients who are interested in having a non-medicinal way of eliminating their tobacco smoking. So, there's a lot of things that can be done at the hospital.

Host: Sounds like it. That's great. So, what symptoms, doctor, could mean we have a breathing issue and at what point should someone see a doctor such as yourself about it?

Dr Rajendra Rampersaud: One of the amazing things is that when people have a sense of shortness of breath or the medical term that we use is dyspnea, and that can be a sign of a lot of different disorders. So obviously, it could be a pulmonary thing where the patient may have a breathing disorder, but it could also be a cardiac thing. So if the patients have a cardiac issue, the symptom that they may experience is a shortness of breath. Say, for example, the patient has a significant anemia where their blood count is low, so they can also have the sensation of shortness of breath. Say the patient has an anxiety disorder, musculoskeletal problem. So, you know, one of the most common symptoms any patient goes to any type of physician is the sense of shortness of breath or what we call dyspnea.

So, the general rule is that if the dyspnea or the shortness of breath is prolonged. So say for example, it's a couple of days or say that it's even a few hours, but it's unremitting and it's not really getting better. That's something that should be assessed by someone sooner than later. Again, because there's so many different things it can be, if the patient's symptoms are worsening or they're just not getting any better and you don't have a good explanation for it, that's the time that you should seek some kind of evaluation.

Host: Gotcha. So next up, let's discuss please how certain conditions affect our lungs in a nutshell. First, how about the flu?

Dr Rajendra Rampersaud: So to group things together, any type of viral infection. So, the big three that is on everybody's radar is influenza. And we did have a significant influenza season this past year, especially influenza B as in boy; RSV, and obviously COVID. So in the short term, these things cause your typical viral symptoms. The patients get body aches. They may have fever. They may have chills. They have congested nose. They have a sore throat. They may have some shortness of breath.

The good thing with these is a lot of them are self-limited, meaning that without sometimes specific treatment, they may just go away. For influenza, there's Tamiflu, which can be taken. It's an antiviral. For the RSV, unfortunately, there's no specific treatment for the RSV. So, if a patient develops an RSV infection, what we basically do is tell them just to symptomatically treat yourself. You know, take a little Tylenol for a fever or a little Motrin for this. Keep yourself well-hydrated.

For COVID, it's a little bit more complicated. So in the outpatient setting, there's the paxlovid medication, which is an antiretroviral, which we know in the high-risk population actually decreases your chance of ending up hospitalized. And more importantly, it ends up, decreasing your chance of actually dying.

So, with these type of illness, those are just viruses and there's so many other ones. Now, you can have a bacterial infection, and these symptoms will be very broad. So, some patients may just have a very mild illness, while others will end up rather sick and end up in the hospital. So, most of these things start off as sore throat, congestion, maybe some fever, shortness of breath, bringing up sputum. I mean, some patients, if their condition is a little bit more complicated, they may be coughing up a little blood. So again, the recommendation is that if things are sort of getting better and you feel that you're moving away from the acute illness, that's great. If things are just not getting any better, or in fact, you're getting worse, that's the best time to come and seek some advice.

Host: Now, two other lung conditions are emphysema and chronic obstructive pulmonary disease, known of course as COPD. What's the difference between those two and how are they treated?

Dr Rajendra Rampersaud: A lot of times, healthcare providers, we sort of mix the two terminologies up. So, emphysema is really a terminology when we look anatomically at imaging. So, what that basically means is that the lung now has sort of deteriorated to the point where the airflow is reduced. And that's what the pulmonary function test assesses.

Now, COPD, like you said, is chronic obstructive pulmonary disease, and that's more of a functional status. So, COPD is something that we pick up on the PFT. So, for example, when the patient does these breath maneuvers, if we see that there is reduction in airflow and it's below a certain percent, so the number we use on our test is 80%. So if you're less than 80% of what you should be for your height and your weight, we categorize that as COPD.

The amazing thing with COPD is that the number one cause certainly is tobacco smoking. So, that's a reversible thing that is the brunt of what causes COPD and emphysema. It's hard to estimate. So when they do assessment of epidemiology to see how many patients are out there that have this condition, it's actually estimated that probably 1 billion people have some form of COPD. And that sounds like an outrageous number, but tobacco smoking is the number one cause, but it could be occupation. So, for example, if somebody works with chemicals, fumes, inhalants, they deal with different things that are getting constantly exposed to over decades of life, they can develop COPD. One of the major causes that we're actually seeing of this condition is people who live in areas of the world who use biofuel. So for example, if you grew up in an area where, because of the resources there, you required charcoal, wood, burning stoves inside the house to heat the house, these type of burning fossil fuels to cook your meals, imagine being exposed in a small area to these things over the course of decades. So, it's one of the causes of COPD that we're actually seeing more and more.

There's genetic causes. So, sometimes the patients are missing something called alpha 1 in their lung, which is a surfactant gene. And those patients can actually develop COPD and emphysema very, very early in life. And again, these numbers sound astronomical, but we certainly see that the number of COPD people and emphysema people are increasing around the world.

Host: So, at the pandemic's height, and this is really interesting, you were the hospital's pharmaceutical lead, and you've since driven St. John's participation in Mayo Clinic's largest plasma program of its kind in the U.S. What does that involve?

Dr Rajendra Rampersaud: One of the difficult things in COVID, again, with a lot of viral infections, there's no specific treatment for them. And even when we, for example, give Tamiflu for the influenza patients, if the Tamiflu is taken within, you know, the first 24 to 48 hours, it shortens the illness in theory by about 18 to 24 hours, only one day. It doesn't really cure something, but it shortens the viral span so that you get better a little bit quickly.

With COVID, right at the beginning, there was really not very much that we had in our armamentarium to sort of help the patients. And one of the interesting things that the Mayo Clinic was doing is that they had this amazing, very large network where you would sign up with their plasma protocol. So basically, if a patient developed COVID and then they developed antibodies against the COVID virus, they would harvest these antibodies and then we would infuse them into patients, who were at very high risk of illness and death from COVID. And this was done through the New York City Blood Bank and what we would do is they would type the blood and then we would request for this plasma to be given to them. And the reason why it's called convalescent plasma is because the patient was convalescing from the illness, and they had already built antibodies. The data, unfortunately, was sort of mixed. And I think that one of the reasons was that because we didn't have a lot of things to treat the patients, our selection of the patients at that time probably wasn't the best selection. So, we were using it in patients who were probably too sick to receive it. So, for example, as a last resort, and to say, well, we don't have very much else, let's just try it. So when these numbers are calculated, statistically, the patients who are called outliers, meaning that they would not have recuperated either way, are sort of included in these numbers.

Now, over the past several years, they've actually used this incredible data set to actually show that if the patient had the right demographics and they received something called high titer. So for example, sometimes when we got the plasma, it was low titer, meaning that it didn't have a lot of antibodies in it and that high titers meant it had a lot of antibodies. So if you were the appropriate patient and you received high-titer convalescent plasma, there was actually some positive outcome for it. And again, this was the sort of thing that especially being in healthcare and seeing all these people getting sick and those who were ending up in the ICU on ventilators, we really wanted to do something.

The good thing was it was also safe for us to give. So, our sort of instinct to give it to people who were a little bit sicker that may not have had an improvement, we also gave it to them as well, just hoping that it would do something. And I can certainly tell you that, for myself, seeing it in action, on the right patient, it was actually quite amazing, But again, it's hard to actually pick up which exact patient would be the right person to use that high-titer convalescent plasma.

Host: Yeah, I'm sure it's very rewarding, to say the least, to be able to do that kind of work, especially with what we've all been experiencing in recent years. Switching gears, before we wrap up here, doc, as the leader of St. John's Sleep Center, can you explain, please, sleep apnea for those that have heard the term, may not know exactly what it is, and how is that treated?

Dr Rajendra Rampersaud: So like I said before, if you look at how many different types of sleep disorders, depending on the resource, you'll see there's actually 70 to 90. A lot of them are sort of grouped together, and it ranges from something like sleep apnea to something that is ubiquitous in a lot of the population, such as insomnia.

So, the sleep apnea syndrome is something that we felt many years ago, there was only one type of sleep apnea. And, you know, the old adage, the more you dig, the more you'll find. So, we actually recognize there's actually more than one type of sleep apnea. The most common type of sleep apnea is called obstructive sleep apnea. And basically, what that means, and the example that I like to give, is imagine a garden hose. And if there's a kink anywhere along the way, there's turbulence that's created. So, if you can imagine that the air flow track starts off at the nose and the mouth, and as air passes into these structures, if there's any structure that causes turbulence of air, this can be audible as a snore. So, not everybody that snores has sleep apnea. And basically, what we suspect is happening is somewhere along the track, there is a blockage of airflow.

And during the sleep test, which is actually quite easy, it's not painful in any way, the monitoring devices are all hooked up to the patient by little sticky pads that don't damage your skin or your hair or anything. And what we're basically assessing, is there a blockage when the patient is breathing? And if this is happening for about five times an hour, that's considered mild sleep apnea. If it's happening 15 times an hour, it's considered moderate. And if it's severe, it's 30 times an hour. Now, just say the patient has a significant cardiac history, these subset of patients can actually develop a very specific type of sleep apnea called central sleep apnea. Say the patient has a neurologic condition, those patients can actually develop central sleep apnea as well. So, we found that there's so many different types of sleep apnea. The children, one of the most common reasons a child will have a tonsillectomy is because of pediatric sleep apnea. So, we study children as young as three years old. The little ones less than three, they can actually have their own very special types of sleep apnea, which are treated in a very different way rather than surgical or tonsil or adenoid surgery.

Now, when it comes to the treatment for a lot of patients, the main risk factor for sleep apnea is being overweight. So, if the patient is overweight, what happens is there's extra pressure and stress on the airway. And there's what creates this narrowing of the airway. So, the global plan for that person over the course of time would be to try to get down for their ideal body weight for their height. So, that would be the general recommendation over the course of time.

In the short term, there's CPAP, which stands for continuous positive airway pressure. Basically, what this is, is that the patient has a small machine. The interface to the patient is a small mask, and the mask is basically providing the machine an air stent. So, it's creating an air pressure in the airway that does not allow the airway to collapse.

Other things, so like I said, for ones, they get surgery, but for the adults also. So, say an adult didn't have a tonsil surgery. Say the adult has an abnormality with their palate, which is the roof of the mouth, say the patient has a small jaw, they can actually extend the jaw out. So, it sounds kind of crazy, but that can happen.

One of the interventions that's really then very popular recently is this Inspire device. So, it's a little pacing device that they place under the skin. And basically, what it does is it moves the tongue muscle forward. So when the patient's tongue is about to move back into the airway to collapse, it actually moves that forward. During the Super Bowl, they had a lot of commercials for the Inspire. So, that was pretty smart on their part.

Another thing that's really utilized amongst a lot of patients with mild to moderate sleep apnea is what's called a mandibular advancement device. So, our dental colleagues figured out that if they make like a mouth guard for the patients, and they wore that when they're sleeping, it would actually keep the jaw and the tongue in a forward neutral position, and that would alleviate sleep apnea. So, there's a lot of different things depending on the patient's age, their medical history, how severe the sleep apnea is, what they feel that their symptoms are. But, fortunately, there's a lot of things that can be done for treatment of sleep apnea.

Host: All right. Well, great information all the way around. Folks, we trust you're now more familiar with respiratory illnesses and how they're treated. Dr. Rajendra Rampersaud, thanks so much again.

Dr Rajendra Rampersaud: Thank you.

Host: And for more information, please call St. John's Physician Referral Service, 914-964-4DOC, that's the number 4-D-O-C, or email them at findadoc, D-O-C, @riversidehealth.org. Now, if you found this podcast helpful, please share it on your social media. I'm Joey Wahler, and thanks again for listening to Riverside Radio HealthCast from St. John's Riverside Hospital.